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Redwood Health Information CollaborativeHealth Information Technology SolutionsPartnershipHealthPlan of CaliforniaLyman Dennis, CIO

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What is PHC? A health plan for low-income and persons with

disabilities (ne “aged, blind and disabled”) Mission is -- “To help our members and the communities we serve be

healthy.” 93,000 members in Solano, Napa and Yolo counties. 150 employees Located in a Fairfield business park $260 million annual budget By law, must show cost savings to State One of lowest administrative cost levels among Medi-Cal

plans (under 5%)

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Service Area

Three Counties Solano Napa Yolo

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Medi-Cal Health Plan Models A score of years ago, then-DHS reconfigured

Medi-Cal Model 1 – two-plan model, competing plans Model 2 – geographic managed care

Needed a model 3 for low-population & some other counties Too small for 2 plans Too small for one plan if only “mandatory” members

Solution: County Organized Health System (COHS) 95+% of all Medi-Cal eligibles in service area

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Why Does COHS Work?What were problems for a Medi-Cal eligibles prior

to reform? Few physicians accepted Medi-Cal due to low

reimbursement, patterns of care issues Especially true for specialists ER a major source of care – when problem

became acute No continuity of care Little preventive care

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Effect of COHS Increase provider reimbursement and scope of

services to the member Improve access to care Focus on primary and preventive care Reduce use of Emergency Room for routine

care Improve the quality of care Establish managed care incentives Run a locally responsive organization

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PHC Health Care Effect Reduced Emergency Dept. use by 52% Reduced hospital utilization by 62% Implemented Case Management Programs (prenatal,

asthma, diabetes), renal, cardiac) Implemented Disease Management Programs (asthma,

diabetes, renal, cardiac) Complex case management program, new Added Substance Abuse benefit Enhanced Nutrition benefit Enhanced Transportation benefit Improved quality of care by working with national quality

standards (HEDIS® and NCQA)

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Quality Awards - 1 HEDIS 1999 Gold award

Among top performers in State (of 22 Medi-Cal plans)

HEDIS 2000 Bronze award, most improved for one measureTied for third in State

HEDIS 2006 Silver awardSecond in State

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Quality Awards - 2

Best Clinical & Administrative Practices (by invitation)BCAP 3 – asthmaBCAP 4 – children with special healthcare

needs HealthLeaders

Top Leadership Team 2005 Finalist

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Leadership

18 Board Members from all 3 counties Physicians, Hospitals, County, Consumer/Advocate,

Nurse, Community Clinic, HMO, City, Business, County Supervisor

Spirit of community cooperation Significant work done by committees Meetings open to the public -- transparency

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Lines of Business

Medi-Cal – Solano, Napa, Yolo (S/N/Y) Healthy Kids – S/N/Y, Sonoma Medicare Advantage (dual eligibles) – PartnershipAdvantage – S/N/Y

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Options for Medi-MediDual Eligibles.

FFS Medicare(Parts A and B)

If a Dual Eligible stays in Medicare fee-for-service:

Medicare Part D(Prescription Drugs) Medi-Cal

Medicare Parts A and BMedicare Part D

Medi-Cal

If a Dual Eligible chooses PartnershipAdvantage:

Medicare Parts A and BMedicare Part D

Medi-Cal

If a Dual Eligible chooses another Medicare Advantage plan:

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Provider Network for PA

All 7 hospitals in all 3 counties All 3 major medical groups

SRMG (Solano)SWMG (Yolo)Woodland HealthCare (Yolo)

All 17 community clinic sites 10 Skilled Nursing Facilities

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Role of IT

20 years ago – IT was service unit to do accounting, provide reports

Today – strategic tool to change the way the organization performs its functions Huge potential to streamline operations

More electronic functions Replace paper, as with TARs, RAFs

Only beginning to address strategic functions at PHC

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Vision of IT

Support the mission of health care to safety net users

Do the strategic functions well Do support well Major projects intervene – PA, AMISYS

Advance, expansion Function of scale which growth will help solve,

so growth is partially self-correcting Excellent IT staff

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Background of PHC IT

Package Systems Managed Care System – AMISYS package,

migrating to AMISYS Advance Financial Systems – MultiView packageIn-house Developed Systems Administrative Systems Clinical Systems Virtual Clinical Network (VCN)

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AMISYS Advance

New version of managed care system Supported by vendor Current supported hardware Runs on HP 9000 system – Unix operating

system, Oracle database Graphical user interface

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AMISYS Advance

Largest project ever for IT Sept 06 – est.140 jobs; Aug 07 – 350 jobs New version of AMISYS Advance, 3.1.x New scheduler: Active Batch, new version New platform: Unix New database: Oracle New scripting

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AMISYS Advance

Changes in EDI maps (32 distinct maps, some used for many providers)

Changes in eHealth Applications (eEligibility, eRAF, eTAR, status checking applications, eCIF, M2)

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PA Tracker (32 screens) Supports marketing Tracks the enrollment request from receipt until the

member is enrolled / disenrolled in PA product (CMS transaction exchange)

Provides interfaces to Mange enrollments/ disenrollments requests Communicate between Marketing, Member Services, IFOX,

CMS and AMISYS Correct and resubmit IFOX or CMS rejections of transactions

Submit enrollment, disenrollment requests (data files) to IFOX

Manages unsolicited disenrollments and displays only important transactions

Tracks the status of a request (enrollment / disenrollment) No ongoing membership discrepancies. A sister plan has

1400 of 9000 or 15%.

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Network

To cope with transaction volume -- Upgrade to gigabit backbone; separate

network for backup Single backup system for HPs and servers Upgraded firewall Upgraded switches

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Other Changes

Telephone Systems and Service Sought upgrade New state-of-the-art system for same price

Redeveloped PHC Website Business Objects

Expansion of existing reporting tool capacity TAR Status Checking

Addition to eHealth toolset HEDIS Data Analysis

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Other (cont’d)

Frugality Savings AMISYS Advance $800,000 one time

Software Hardware UPS

Telephone service $50,000 per year (50%) Refund fr McKesson for 1st Year $17,600 one time GeoAccess $16,000 for 7 yrs (50%)

Total $883,600 Contributed to

Medicare Advantage Application Knox-Keene Application

HIMSS CHO Task Force – national group to develop database of innovative

community health organization IT projects – 40+ members

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Administrative Systems

eEligibility eEligibility Download eRAF, eTAR RAF Status Checking,

TAR Status Checking eTAR Attachments Tumbleweed secure

email

eClaims Submission, Claim Status Checking

eClaims Inquiry Form IVR, IVR Outcall eAdministration Claims routing

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Clinical Systems

ER to Clinic Appointment Preventive Prompts Medical Management (M2) eCall Disease Management (packages)

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ePreventive Prompts

18 conditions detectable from claims data Design assistance from Dr. Jeff Gee at

Kaiser Oakland Printable when eEligibility checked at

provider’s front desk

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Functions of M2 (48 screens)

Add a TAR Manage a patient

Indicate level of careDeny a day or change level of careMove to/from acute care

Modify a TAR Detect and managed duplicate TARs (merge

or deny)

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eCall

Can be used to notify members of preventive care that is due

Can be used for any reminder activity eRAF and eTAR collect current member phone

numbers – about 900 numbers updated per month

In La Clinica tests, 85% of 200+ members were reached in 2-3 days by phone

Learning: telephone contact of Medi-Cal members does work!

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Secure eMail

Operational in June 2006 Very powerful tool for providers to share

information on patients seen Can email a member securely and receive

a secure response

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VCN

Record LookupEncountersLab resultsPrescriptions & compliance

Summary Medical History (from eEligibility)

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Lookups on VCN

0

2000

4000

6000

8000

10000

12000

14000

16000

April 04May June July

AugustSeptember

OctoberNovember

Dec 04 Jan 05February

March April May JuneJuly 05

Lookups

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Last Year in IT

New VOIP telephone system; new call center system(2); new call recording system

HSS DRG/APC system Expand to 2nd floor Upgrade to ver 11 of Business Objects

(initially bad version) – GREAT tool Removed SSNs from visible fields Temp fix for NPIs

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Last Year in IT (cont’d)

Mock disaster recovery drill Made repeated changes to EDI formats to/from

CMS/IFOX as requires. Assisted in many pharmacy formulary changes

and submissions to CMS. DocSite, IntelliCred, Catalyst, etc. Refined Clinic Alliance reporting Investigated ePrescribing

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Other initiatives

Leadership Mentorship for each IT staff member Sue Schade, CIO, Brigham & Women’s Hospital

Post AMISYS Advance & Key Expansion Steps Cross-training Zero defects

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Next IT Applications

RAF and TAR Acceptance from Fax without printing into routing system for archive

CRM System – avoid all AMISYS functions except claims

Claims input outsourcing (Claims & IT)

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IT Summary

“Function like a software development company, not an operating business” – sense of urgency

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NEPSINational ePrescribing Safety Initiative

Free (to provider)

ePrescribing System

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Value of ePrescribing

Between 1.5% and 4% of prescriptions contain errors potentially detrimental to patient

Adverse drug events occur for 5% to 18% of ambulatory patients

One of 131 ambulatory patient deaths due to medication error (US DHHS report on Web).

42% of serious ADEs are preventable (Gandhi et al., NEJM, 2003)

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Value of ePrescribing (cont’d)

Most prescriptions are for refills. Average office time per refill from 2 to 10 minutes 900 million prescription-related calls per year (30%

of prescriptions require callbacks) Sierra Medical Associates, a large Las Vegas

medical group increased use of generics by 8.2% through ePrescribing.

With healthplan incentives, providers may gain substantially from increased use of generics.

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Regulatory Background

Doctors are not required to prescribe electronically Healthplans ARE required to “support” ePrescribing (by

Medicare Modernization Act of 2003) After 2009, physicians who prescribe electronically are

required to utilize final standards approved by CMS in 2008 Preliminary Standards

NCPDP SCRIPT Standard Telecommunication Standard Guide ASC X12N 270/271

Study of pilots at 5 locations published in 2007 by Secretary Leavitt. 3 of 6 standard deemed acceptable (work as proposed) Workarounds exist for other standards

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DEA & ePrescribing of Controlled Substances DEA prohibits ePrescribing for controlled substances DEA options for CS prescribing

Schedule III-V. Written, physically signed & faxed to pharmacy (considered “oral” prescription) or faxed to pharmacy and verified by pharmacist calling the physician office.

Schedule II. Fax to pharmacy but pharmacy must also receive actual original written prescription

Generation of a prescription by an electronic device that is not signed or has an electronic or digital signature is unacceptable to DEA.

For Medi-Cal, must use 3-part form effective Oct 1 2007 copy, erase or counterfeit & 2008 “and” if not ePrescribed or faxed.

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Benefits of ePrescribing

To Members Reduced medication errors Faster communication of prescriptions to pharmacy Physician & PHC better able to monitor drug compliance

To Practices 50% cost savings from increased use of generics through

QIB Staff time savings w fewer call-backs & easier refills Access to patient-specific formulary Better information on patient medication history

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Benefits ofePrescribing (cont’d) To PHC

Better formulary compliance (saving) Reduced medication errors (saves cost of

treating medication-induced conditions)

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Allscripts eRx NOW SureScripts connection to 95% of pharmacies in 50

states Accumulates medication history Can add allergies Checks for drug-drug effects Allscripts promises an export of patient data if physician

decides to move to a full EHR Preview

Pilot with half a dozen interested physicians Demographics from PMS for $299 + $20 per month Providers can access PHC formularies, $0.20 per

access) Costs would be paid by PHC for pilot ( recovered through

cost savings)

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Interface Server

Cluster Database

Server

erxnow.allscripts.com

Web Servers

Internet

eRx NOW Architecture

Interface Server

Other

PMS’s

Patients

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Key Benefits

Cost savings from increased us of generics 50% to practice through QIB

Simpler prescribing and renewal Staff time savings w fewer call-backs

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Future Plans for PHC Continued focus on quality improvement Improve use of technology with providers & members Future expansion (Sonoma, Marin, Mendocino, Lake

Counties) Explore ways to decrease the number of uninsured in

our communities (with Coalition & others) Add cost-effective benefits Explore options to facilitate placement in long term care

facilities

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Questions

Lyman DennisCIOPHCLdennis@partnershiphp.org707-863-4405